Membership And Account Application
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1American Eagle Financial Credit Union, Inc.
Membership and Account Application
Directions: Members, New Members and Joint Members, if applicable – Please complete Section I and II.
I. TYPE OF ACCOUNT
A minimum $5.00 deposit and a completed membership application are required to open a savings account. This deposit makes you a “member-owner” of American
Eagle Financial Credit Union, Inc. and entitles you to use the Credit Union’s services.
New Member
Add Joint Owner
Existing Member
AEFCU Member No. (CIF) ___________________________________
II. GENERAL INFORMATION
Primary Owner
FIRST NAME, M.I., LAST NAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
ELIGIBILITY FOR MEMBERSHIP
RESIDENCE ADDRESS (NOT PO BOX)
CITY, STATE, ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY, STATE, ZIP
HOME / CELL PHONE
WORK PHONE
PASSWORD
EMPLOYER
E-MAIL ADDRESS
DRIVER’S LICENSE NUMBER
STATE
ISSUANCE DATE
EXPIRATION DATE
Joint Owner # ______ of # ______
Existing Member:
Yes
No
AEFCU Member No. (CIF) ___________________________________
FIRST NAME, M.I., LAST NAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
ELIGIBILITY FOR MEMBERSHIP
RESIDENCE ADDRESS (NOT PO BOX)
CITY, STATE, ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY, STATE, ZIP
HOME / CELL PHONE
WORK PHONE
PASSWORD
EMPLOYER
E-MAIL ADDRESS
DRIVER’S LICENSE NUMBER
STATE
ISSUANCE DATE
EXPIRATION DATE
I hereby make application for membership in and agree to the bylaws, as amended, of American Eagle Financial Credit Union, Inc. (Credit Union) and subscribe for at
least one non-transferrable share. I certify that: I am within the field of this Credit Union, the information provided on this application is true and correct, and my signature applies
to all accounts under my name at this Credit Union.
Under penalties of perjury, I certify that: (1) the number shown on this form is my correct taxpayer identification number; and (2) I am not subject to backup withholding
because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to withholding as a result of failure to
report all interest or dividends, or (c) the IRS has notified me I am no longer subject to backup withholding, and (3) I am a U.S. person (including a U.S. resident alien).
By signing below, each of the signers acknowledges receipt of and agrees to the American Eagle Financial Credit Union, Inc. Member Account Information Agreement,
and future amendments. You also understand that when you receive your Online Banking and Bill Pay Agreements, you will read the terms and conditions for the said agreements,
and your use of these items will constitute acceptance of the terms and conditions in the agreement.
_______________________________________
________________________________________
PRIMARY OWNER SIGNATURE
DATE
JOINT OWNER/CUSTODIAN SIGNATURE
DATE
III. ACCOUNT INFORMATION – CU USE ONLY
ACCOUNT TYPE
ACCOUNT NUMBER
Primary
Joint
Other
CD Dividend
CD Type
ODP
POA / Conservator / Custodian
IRA / Share
Opt-In
________________________
_______________
__________
________________________
_______________
__________
________________________
_______________
__________
________________________
_______________
__________
________________________
_______________
__________
________________________
_______________
__________
________________________
_______________
__________
IV. MEMBER VERIFICATION – CU USE ONLY
USA PATRIOT ACT VERIFICATION (MIP)
Primary Owner
Joint Owner
In Person
Not Present:
In Person
Not Present:
Driver's License
State ID Card
US Passport
Driver's License
State ID Card
US Passport
Military ID
Other: _________________________
Military ID
Other: _________________________
ID #: ____________
State of Issuance: ____________
ID #: ____________
State of Issuance: ____________
Issued: ____________
Expires: ____________
Issued: ____________
Expires: ____________
Combined Stmt
Check Order
ATM/Debit Card
Combined Stmt
Check Order
ATM/Debit Card
Branch: ____________________ Employee #: _________ Date Opened: __________ OFAC Verified By: __________ Membership Officer: __________
Member and Account Application
330-051 (Rev. 01/2015)
Federally insured by NCUA. Equal Opportunity Lender
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